Honoring Choices Minnesota
July 19, 2012

Co-chairs: Tom von Sternberg, MD, Beth Waterman
Membership includes representatives from Regions Hospital,
Specialty Care, HealthPartners Home Care, Geriatrics,
Hospice & Palliative Care, Primary Care and the Health Plan
Areas of Focus:
REGIONS
-Jim Risser, MD
-Beth Heinz
-Danielle
Tencate Cole
HEALTH
PLAN
PRIMARY
CARE
-Lora Heidin
-Karen Kraemer
-Kate Kellet
SPECIALTY
CARE
-Terry Carter
-Tyler Schmidtz
-Rachel Nygard
HOME CARE,
GERIATRICS,
HOSPICE &
PALLIATIVE CARE
-Mary Lou Irvine
-Tom von Sternberg, MD
-Beth Werner
COMMUNITY
-Mary Lou Irvine
-Tom von Sternberg, MD
-Donna Zimmerman
-Beth Heinz

• Criteria in Epic
• Auto referral for Medical ICU patients over 85
• Surgical ICU will add auto referral
• Presence at care rounds
• Expanding to Emergency Dept: Physician Orders for Life
Sustaining Treatment (POLST) and consults
• Increasing Palliative Care provider coverage
• Partnership with oncology Nurse Practitioner

Regions Palliative Care
Consults / 1,000 Discharges
70
60
50
90
80
40
30
20
10
0 янв.09
апр.09
июл.09
окт.09
янв.10
апр.10
июл.10
окт.10
янв.11
апр.11
июл.11
окт.11
янв.12
апр.12

• Using the Honoring Choices and POLST forms
• 56% of patients 65+ have Advance Directives
(1/11-2/12)
• Lean project
– Design workflows to obtain Advance Directives and ensure copy is available in
Epic
– Interdisciplinary effort (Palliative Care, Hospital Medicine, Nurse, Care
Management, Chaplaincy, HIM)
– Comprehensive review of current process, identification of potential barriers, and ideas for new models
– Early fall 2012 goal for implementation

• Staff training and awareness resulted in increased referrals for Palliative Care, Advance Care Planning and Hospice
• Advance Directive measure: 8543 patients screened,
3262 completed
• EBAN project successes spread to all patients/members

Hospice, Palliative Care & Adv Care Planning Referrals
Disease & Case Management
600
300
0
Total
Hospice Referrals
Advance Care Planning Referrals*
Palliative Referrals
In-hospital Hospice Collaborations**
2 100
1 800
1 500
1 200
900
64
112
67
2009
243
64
112
67
171
56
225
521
2010
973
171
56
225
521
217
705
319
882
2011
2 123
217
705
319
882

• Eban is a letter from the Asanti people of Ghana. It represents security, safety and trust. It was chosen as the symbol of the EBAN Experience to represent the coming together of cultures to improve the health of all.

• Adopted by HealthPartners as an organizational initiative for addressing health disparities and equitable care in 2011.
• The EBAN Experience is a year-long collaborative of teams created to address issues of health disparities in the communities served by HealthPartners.
• Creative strategies that partner health care professionals and community members.

• Areas of focus include:
– Increased rates of advance directives
– Increased pediatric immunization rates
– Improve diabetes health outcomes through education
• Results
– Improved the rate of completed Advance
Directives in the MSHO African-American population from 25% to 32% by year end.
– Narrowed the disparity gap between Whites and
African Americans from 25% to 21%

• Current information in Health and Wellness tab in
“Additional Resources”
Future Plans:
• New “Care-giving Health Center” in Health &
Wellness tab will provide information on advance care planning, shared decision making, etc.

• Workflow is with care team, with Epic prompt and notary
• Pilots at Riverside, Brooklyn Center, Como, West for patients 65+
• Using short form with brochure and/or Honoring
Choices form
• Expanding to all locations in 9/12 and then to younger population, i.e, 50 and over
• Staff Education

• Sharing NP resource with Regions Palliative Care
• Population: new diagnosis, pancreatic and lung cancer, any stage 3 and 4
• Facilitated conversations with nurse practitioner or social worker
• Measure: since 1/11, 701 (23%) of all cancer patients have Advance Directives in EPIC

• Population: Heart Failure Class II, III, IV
• Providers initiate conversation then RN “facilitator” meets with patient
• Measure: 83.5% of Class III and IV, 45% of Class II have Advance Directives

• Population: Chronic Kidney Disease stage 4, 5
• Provider initiates conversation then RN facilitation or
Advance Care Directives Class (group session), follow-up phone call

• Standardized workflow, documents and where to locate in EPIC.
• Measure: 75% with Advance Directives documented
• Increased long term care facility adoption of POLST

• Facilitated discussion with admission
• Hospice measure: 960 of 1000 patients in 2011 completed POLST
• Palliative Care measure: 273 admissions in 2011 with 227 completed Advance Directives using
Honoring Choices Minnesota document
• Coordinating with inpatient Palliative Care consult team and weekly rounding

• Alliance of Community Health Plans (ACHP) Palliative
Care workgroup
• National Quality Forum (NQF) Hospice workgroup
• Institute for Healthcare Improvement (IHI): The
Conversation Project by Ellen Goodman
• EPIC and Health Information Exchange
• End of Life training course with Jim Risser, MD and
Richard Heinrich, MD (2 days, twice a year)
• St. Paul Area Council of Churches
• EBAN project

• CEO and Senior Leadership support
• Member of Advisory Committee
• Ambassador Program participation (Kate Kellet with primary)

REGIONS
Jim Risser MD, Beth
Heinz, Danielle
TencateCole
• Inpatient and ED
Palliative Care consult
• Outpatient resources for consults o Oncology clinic partnership
• Focus for FIT
Quality team
• LEAN project:
Advance Directives
• Measuring patient anxiety and pain
HealthPartners
End of Life/Palliative Care Initiatives
HEALTHPLAN
Lora Hedin, Karen
Kraemer
• Palliative Care benefit o Commercial o MSHO
• Care and Disease
Management o Spreading learnings from
EBAN project o Referrals to
Palliative Care,
Advance Care
Planning,
Hospice
• HealthPartners.com
PRIMARY
CARE
Kate Kellet
• Advance Directive workflow o Short form, brochure and/or
Honoring
Choices form o Facilitator available o Pilots at
Riverside,
Brooklyn Center,
West, Como; to all sites 9/12
• Epic “prompt” on health maintenance screen
• Population Health workflow component
SPECIALTY
CARE
Terry Carter, Dave
Slowinske, Tyler Schmidtz,
Rachel Nygard
• Cardiology CHF patients class II, III and IV o Honoring choices form and facilitator
• Oncology o New cancer diagnosis patient identified in previsit planning o Focus on pancreatic, lung and any Stage 3 and 4 cancers o Honoring choices form and facilitator
• Nephrology o Chronic Kidney
Disease patientsstage 4 and 5 identified in previsit planning o Honoring Choices form, facilitator or
Advance Care
Directives class
• Cardiology CHF All-
Collaboration with hospice and palliative care o Pulmonary o Neurology
GERATRICS,
HOME CARE
& HOSPICE
Mary Lou Irvine, Tom von Sternberg MD, Beth
Werner
• Geriatrics/Home
Care o Honoring choices or
POLST form o Standardized workflow for
EPIC or out of system providers and homecare EMR o Nursing home adoption of
POLST form
• Palliative
Care/Hospice o Facilitated discussion on advance care planning at admission o Honoring choices or
POLST form o Coordination with inpatient palliative care consult team
COMMUNITY
Mary Lou Irvine, Tom von Sternberg MD,
Donna Zimmerman,
Beth Heinz
• ICSI Workgroup
• ACHP Palliative
Care workgroup
• HIE/EPIC
• Honoring Choices
MN o Ambassador program o Public television
• EBAN project
• St Paul area Council of Churches

• Meeting cultural needs of patients
• EPIC modification that meets needs of community
• Limitation with Palliative Care benefit
• Improving website location and accessibility
(HealthPartners.com and My Partner)
• Building awareness
• Incorporating into Employee Wellness Program